Provider Demographics
NPI:1801852017
Name:ILGEN, REBECCA GRACE (PAC)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:GRACE
Last Name:ILGEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HALL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CRISFIELD
Mailing Address - State:MD
Mailing Address - Zip Code:21817
Mailing Address - Country:US
Mailing Address - Phone:410-968-1200
Mailing Address - Fax:410-968-3005
Practice Address - Street 1:201 HALL HIGHWAY
Practice Address - Street 2:
Practice Address - City:CRISFIELD
Practice Address - State:MD
Practice Address - Zip Code:21817
Practice Address - Country:US
Practice Address - Phone:410-968-1200
Practice Address - Fax:410-968-3005
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S28250Medicare UPIN